26 Juni 2020 Materi Webinar

CASE SHARING :
TREATING CV PATIENTS DURING

COVID-19 ERA
Diah Retno Widowati, MD, FIHA, FAsCC

RSUP Fatmawati, Jakarta
INTRODUCTION
• Severe acute respiratory syndrome coronavirus 2 (SARS-

CoV-2) causing coronavirus disease 2019 (COVID-19)
has reached pandemic levels
• Patients with cardiovascular (CV) risk factors and

established cardiovascular disease (CVD) represent a
vulnerable population when suffering from COVID-19
• Patients with cardiac injury in the context of COVID-19

have an increased risk of morbidity and mortality
ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic
Covid19.go.id
Covid19.go.id
Risk Factors Covid-19 and CV Complications
Driggin E, et al. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic. Journal of the American College of Cardiology 2020.
HEMOSTATIC ABNORMALITIES IN COVID -19
Infection with the novel coronavirus SARS-CoV-2 (COVID-19) has been associated
with inflammation and a prothrombotic state
→ RISK OF THROMBOEMBOLISM
Pic from: https://rebelem.com/covid-19-thrombosis-and-hemoglobin/, accessed on 5 May 2020

CASE 1
• Perempuan, 71 th
• Mengeluh sesak nafas bila aktivitas dan memberat saat
tidur berbaring sejak 3 hari SMRS. Tidak ada nyeri dada.
• Tidak dijumpai demam, batuk ataupun sakit tenggorokan.
• Pasien seorang ibu rumah tangga, tidak ada riwayat
perjalanan ke daerah endemis ataupun kontak dengan
penderita Covid 19.
• Faktor risiko KV : hipertensi.
• Riwayat pembengkakan jantung sejak 3 tahun terakhir.
CASE 1…..
KU : Sakit Sedang : GCS E4V5M6

TD : 103/56mmHg
N : 96 bpm, regular
RR : 28 x/min
Tax : 37.3 oC
JVP : 5+4 cmH2O
Saturasi O2 : 98% room air
Jantung : S1-2 normal, regular, murmur (-), gallop (+)
Paru : Vesikular, ronchi +/+, Wheezing -/-
Ektremitas : akral hangat, edema tungkai bawah +/+
CASE 1….. CHEST X-RAY
• Heart : CTR 65%

• Lung : cephalization (+), infiltrate (+)
• Sharp right costophrenic angle,
• Blunt left costophrenic angle.
C ASE 1….. ECG
Sinus rhythm, rate 105 bpm, axis normal, P wave normal, PR interval 160 ms, QRS complex <120 msec,
Q wave at II, III, aVF,V2-6, ST elevation at V2-V5…. ( == EKG sebelumnya)
C ASE 1…..
Complete Blood Count Blood Chemistry Blood Chemistry

WBC 4,1 10 µ/µL Ureum 29 mg/dL Natrium 138 mmol/l
HGB 12,3 g/dL SC 0.92 mg/dL Kalium 4,07 mmol/l
HCT 38 % Random 114 mg/dL Klorida 102 mmol/l
MCV 85 fL Blood glucose Kalsium total 9,2 mg/dL
MCH 29,2 Pg Albumin 4,2 mg/dL Magnesium 2,5 mg/dL
PLT 179 10 µ/µL aPTT 26.6 detik
NE 78 10 µ/µL kontrol 30,7 detik
PT 13,7 detik Cardiac Marker
LY 16 10 µ/µL
kontrol 14,2 detik Troponin I 0,063 < 0.02 ng/mL
NLR 4,88
LY Abs 1408 /µL INR 0,96
Fibrinogen 499 mg/dL SARS CoV-2
D dimer 2310 ng/mL Swab SARS CoV-2 Positif
CRP 1,0 mg/dL
CASE 1….. ECHOCARDIOGRAPHY
IMPRESSION :
• Dilatasi LA, LV ….. LAVi 42 ml/m2
• LVH eksentris … LVMi 188 g/m2
• Reduced left ventricle systolic function EF Teich 35 % Simpson 33%
• Reduced right ventricular systolic function TAPSE 1.6 cm
• Akinetic at basal mid inferoseptal, anteroseptal, anterior, apicoseptal
apicolateral, apicoanterior. Normokinetic at other segmens.
• Mild MR, Mild TR
• Diastolic dysfunction grade 2
• eRAP 12 mmHg
CASE I…. ASSESSMENT
• Acute Decompensated Heart Failure pada CHF fc IV ec

old anteroinferior MI
• HHD
• Pneumonia (PDP Covid - 19)
CASE I…. TREATMENT
• O2 3 lpm
• Follow up
• Asetosal 80 mg OD
• Atorvastatin 1x 20 mg
• Sesak mulai berkurang pada hari ke-3
• Enoxaparine 1 x 0.4 cc SC
• Swab nasofaring I & II (selang 48 jam) : positif
• Bisoprolol 1x 1.25 mg
• Menunggu hasil swab nasofaring ke-3
• Ramipril 1x10mg
• Furosemide 2x40 mg IV → 1x40 mg IO • Hari ke-6 : d dimer 780
• Spironolactone 1x 25 mg
• ISDN 5 mg SL bila perlu
• Azitromisin 1 x 500 mg
• Vit C 3 x 400 mg IV
• Osetalmivir 2 x75 mg
Disclaimer: Enoxaparin is indicated for prophylactic treatment of DVT in patients who are bedridden due to an acute medical condition such as heart failure (NYHA class III or IV), acute respiratory failure, episode of acute infection
or acute rheumatic disorder associated with at least one other risk of VTE factor. Enoxaparin is not indicated specifically to treat Covid-19 patients. Registration condition differs internationally, therefore Enoxaparin might have
different indication approval outside Indonesia
CASE 1I
• Perempuan, 59 th
• Masuk RS dengan penurunan kesadaran 4 jam SMRS.
• Lemas sejak 1 minggu SMRS. Tidak ada keluhan sesak nafas
ataupun nyeri dada.
• Tidak dijumpai demam, batuk ataupun sakit tenggorokan.
• Pasien seorang ibu rumah tangga, tidak ada riwayat perjalanan ke
daerah endemis ataupun kontak dengan penderita Covid 19.
• Faktor risiko KV : hipertensi dan diabetes.
• Riwayat stroke 1 tahun yang lalu.
CASE I1…..
KU : Sakit berat : GCS 4

TD : 117/62mmHg
N : 96 bpm, regular
RR : 24 x/min
Tax : 36,8 oC
Saturasi O2 : 98% room air
Jantung : S1-2 normal, regular, murmur (-), gallop (-)
Paru : Vesikular, ronchi +/+, Wheezing -/-
Ektremitas : akral hangat,
CASE I1….. CHEST X-RAY
• Heart : CTR 55%

• Lung : cephalization (+), infiltrate
(+)
• Sharp right and left costophrenic
angle,
C ASE I1…..
Complete Blood Count Blood Gas Analysis +

Blood Chemistry Electrolytes
WBC 9,0 10 µ/µL Ureum 199 mg/dL pH 7,266 7.35-7.45
HGB 7,3 g/dL SC 3,1 mg/dL
PCO2 22,7 35-45
HCT 23 % Random 30 mg/dL
Blood glucose pO2 220,4 80-100
PLT 326 10 µ/µL
NE 76 10 µ/µL Albumin 2,6 mg/dL SO2c 99,4 95-100
LY 17 10 µ/µL aPTT 59,9 detik BE -14,7 -2 – 2
NLR 4,5 kontrol 30,7 detik HCO 10,1 22-26
LY Abs 1547 /µL PT 14,7 detik 3-
kontrol 14,2 detik
Blood Chemistry
INR 1,04
Natrium 123 mmol/l
SARS CoV-2 Antibody Fibrinogen 321 mg/dL
Kalium 5,1 mmol/l
SARS CoV-2 Ig M Positif D dimer > 20.000 ng/mL
Klorida 111 mmol/l
CRP 12,9 mg/dL
Kalsium 7,1 mg/dL
total
CASE II…. ASSESSMENT 1
• Penurunan kesadaran ec Hipoglikemia pada DM tipe 2

• Acute Kidney Injury DD/ Acute on CKD
• Anemia
• Imbalans Elektrolit
• Pneumonia (PDP Covid - 19)
CASE II…. TREATMENT 1
• O2 3 lpm
Follow up
• Protokol hipoglikemia
• Koreksi asidosis metabolic
• Pasien mulai sadar penuh keesokan
• Koreksi elektrolit
harinya dan mulai mengeluh sesak nafas
• Transfusi PRC. → Hb 9,9
dan nyeri uluhati.
• Kloroquin 2x250 mg
• Ceftriaxone 2 x 1 gr IV
• Konsul kardiologi hari ke-3
C ASE I1….. ECG
Sinus rhythm, rate 98 bpm, left axis deviation, P wave normal, PR interval 160 ms, QRS complex <120 msec,
Q wave at III, aVF, ST elevation at III, aVF, ST depression at I, aVL,V3-6, Cardiac Marker
QTc 520 msec….
Troponin I >10,0 < 0.02 ng/mL
CASE II…. ASSESSMENT & TREATMENT II
• Acute STEMI inferior late onset • O2 3 lpm
(> 12 jam) • Asetosal 160 mg loading → 80 mg OD IO

• Clopidogrel 300 mg loading → 75 OD IO
• CHF ec CAD
• Atorvastatin 1x 20 mg
• DM tipe 2
• Enoxaparine 1 x 0.4 cc SC
• CKD (eGFR 24 ml/min ) • Carvedilol 2x 3,125 mg
• Pneumonia (PDP Covid - 19) • Ramipril 1x 2,5 mg
• Furosemide drip 5 mg/jam IV → 1x40 mg IV
• Spironolactone 1x 25 mg
• ISDN 5 mg SL bila perlu
• Ceftriaxone 2 x 1 gr IV
• Stop Kloroquin
Disclaimer: Enoxaparin is indicated for prophylactic treatment of DVT in patients who are bedridden due to an acute medical condition such as heart failure (NYHA class III or IV), acute respiratory failure, episode of acute infection
or acute rheumatic disorder associated with at least one other risk of VTE factor. Enoxaparin is not indicated specifically to treat Covid-19 patients. Registration condition differs internationally, therefore Enoxaparin might have
different indication approval outside Indonesia
CASE II….. ECHOCARDIOGRAPHY
IMPRESSION :
• Dilatasi LA, ….. LAVi 52 ml/m2
• LVH concentris
• Reduced left ventricle systolic function EF Teich 30 % Simpson 28 %
• Normal right ventricular systolic function TAPSE 2,1 cm
• Akinetic at inferior, inferolateral, Hypokinetic at anteroseptal, anterior,
apicoseptal apicolateral, apicoanterior. Normokinetic at other segmens.
• Mild MR, Mild TR
• eRAP 8 mmHg
CASE II…. FOLLOW UP II
• Sesak nafas dan nyeri ulu hati berkurang.

• Terjadi melena pada H-6, Hb 8,3 → Aspilet dan Enoxaparine stop.
Tranfusi PRC.
• Creatinin 3,1. → 2,1
• USG Abdomen : sesuai penyakit parenkimal ginjal kronik disertai asites.
• D dimer 3810
DIAGNOSIS OF CARDIOVASCULAR CONDITIONS
IN COVID-19 PATIENTS
Key points
• Initial symptoms of a COVID-19 infection such as breathlessness, chest
pain, or asthenia may mimic the early manifestations of a cardiac disease.
• Also, COVID-19 patients might abruptly develop acute cardiac complications
(such as Acute Coronary Syndrome (ACS) or pulmonary embolism [PE]).
• Critically ill patients for acute CV condition should quickly access medical or
interventional treatment.
• Overlapping clinical presentations and comorbid diseases can make the
diagnostic evaluation of dyspnea a clinical challenge -- might be delayed and
be downgraded to lower intensity levels.
ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic. 21 April 2020.
http://www.inaheart.org/guidelines, accessed on 14 April 2020
PROPHYLACTIC AND THERAPIES ANTICOAGULATION
FOR COVID- 19 NEEDED ???
• A number of randomized controlled trials have been developed to

evaluate the risks and benefits of anticoagulation in patients with
COVID-19
• Interim guidance on recognizing and managing coagulopathy in

patients with COVID-19 has been released by the International
Society of Thrombosis and Haemostasis (ISTH).
ISTH interim guidance on recognition and management of coagulopathy
in COVID-19 2020
J Thromb Haemost. 2020;18:1023–1026.

COVID-19 TREATMENT GUIDELINES
NATIONAL INSTITUTES OF HEALTH 2020
• Chronic Anticoagulant and Antiplatelet Therapy:

• Patients who are receiving anticoagulant or antiplatelet therapies for underlying
conditions should continue these medications if they receive a diagnosis of COVID-19
(AIII).
• Venous Thromboembolism Prophylaxis and Screening:

• For non-hospitalized patients with COVID-19, anticoagulants and antiplatelet therapy
should not be initiated for prevention of venous thromboembolism (VTE) or arterial
thrombosis unless there are other indications (AIII).
• Hospitalized adults with COVID-19 should receive VTE prophylaxis per the standard of
care for other hospitalized adults (AIII)
https://www.covid19treatmentguidelines.nih.gov/.
STEMI DENGAN KECURIGAAN COVID-19

STEMI DENGAN KECURIGAAN COVID-19

ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic. 21 April 2020.
Disclaimer: Enoxaparin is indicated for prophylactic treatment of DVT in patients who are bedridden due to an acute medical condition such as heart failure (NYHA class
III or IV), acute respiratory failure, episode of acute infection or acute rheumatic disorder associated with at least one other risk of VTE factor. Enoxaparin is not indicated
specifically to treat Covid-19 patients. Registration condition differs internationally, therefore Enoxaparin might have different indication approval outside Indonesia
Disclaimer: Enoxaparin is indicated for prophylactic treatment of DVT in patients who are bedridden due to an acute medical condition such as heart failure (NYHA class
III or IV), acute respiratory failure, episode of acute infection or acute rheumatic disorder associated with at least one other risk of VTE factor. Enoxaparin is not indicated
BALANCING EVENTS AND BLEEDING
Risk of events
Risk of bleeding
Risk
Degree of Anticoagulation HOW TO

PREDICT
Hemostasis
BLEED?
Thrombosis
Two sides of the same coin
CRUSADE BLEEDING RISK SCORE
Subherbal S et.al, Circ 2009; 119: 1873

ROCKALL SCORING SYSTEM –
RISK ASSESMENT AFTER ACUTE GI HAEMORRHAGE
Rockall TA, et al. Risk assessment after acute upper gastrointestinal hemorrhage. Gut. 1996 Mar;38(3):316-21.
Singet et al. Ann Intern Med. 2009.
CONCLUSION
• Recognition of symptoms, which may be challenging due to atypical

presentations, can be even more difficult due to significant symptom overlap
with COVID-19 complaints.
• The management of ACS in the Covid – 19 era requires specific

modification in current medical practice.
• A number of RCT have been developed to evaluate the risks and benefits of
anticoagulation in patients with COVID-19
• LMWH has been shown to have anti-inflammatory properties which may
be an added benefit in COVID infection against thromboembolism where
pro-inflammatory cytokines are markedly raised.
If LMWH(Enoxaparin) is not available :
✓ unfractionated heparin could be used,
although this requires more frequent
injections;
✓ An alternative is fondaparinux, but whether
this drug has the postulated anti-
inflammatory benefits of heparin is
unclear.
Disclaimer: Enoxaparin is indicated for prophylactic treatment of DVT in patients who are bedridden due to an acute
medical condition such as heart failure (NYHA class III or IV), acute respiratory failure, episode of acute infection or acute
rheumatic disorder associated with at least one other risk of VTE factor. Enoxaparin is not indicated specifically to treat
Covid-19 patients. Registration condition differs internationally, therefore Enoxaparin might have different indication
approval outside Indonesia
ww.thelancet.com/haematology Vol 7 June 2020

DR. DIANA PARAMITA, SPPD,
KHOM
KSM ILMU PENYAKIT DALAM, RSUP PERSAHABATAN
Trend of COVID-19 in Indonesia (www.covid19.go.id)
INTRODUCTION
❑Patients with COVID-19 are at increased risk of venous
thromboembolism (VTE), which is a deep vein thrombosis (DVT) or
pulmonary embolism (PE)
❑COVID-19 may predispose to both venous and arterial thromboembolic
disease due to excessive inflammation, hypoxia, immobilization and
diffuse intravascular coagulation (DIC) (Klok et al., 2020)
❑It is still unknown if this is higher risk than other critically ill patients.
❑An elevated D-dimer is commonly seen in patients with COVID-19 (40-
50%)
❑Pulmonary embolism should be considered in admitted patients with
COVID-19 who have a sudden onset of oxygenation deterioration,
respiratory distress of hypotension
VTE CAUSE
KOMORBIDITAS Mortalitas
>>
Badai Sitokin
• JACC. VOL. 7 5 , NO . 2 3 , 2 0 2 0
Patofis: Cytokine Strom
D-dimer & prolonged PT sebagai prediktor mortalitas

• JACC. VOL. 75, NO . 23, 2020
Clinical Sign & Symptom of VTE
The signs and symptoms of a DVT include:
Swelling, usually in one leg (or arm)
Leg pain or tenderness
Reddish / blue skin discoloration
Leg (or arm) warm to touch
The signs and symptoms of a PE include:

Sudden shortness of breath
Chest pain-sharp, stabbing; that may get
worse with deep breaths
A rapid heart rate
Unexplained cough, sometimes with blood-
streaked mucus
31% incidence of thrombotic complications in ICU patients
with COVID-19 infections is remarkably high and well
omparable to the VTE incidence in other patient categories
with overt DIC.
Our findings reinforce the recommendation to strictly apply

pharmacological thrombosis prophylaxis in all COVID-19
patients admitted to the ICU, and are suggestive of
increasing the prophylaxis towards high-prophylactic doses
• Klok FA, et al. Thrombosis Research 191 (2020) 145-7.

Coagulation monitoring
1) Baseline admission blood work: CBC, INR, PTT, fibrinogen, D-dimer
level
2) Coagulation monitoring:
◦ Check a CBC daily if ordering labs daily
◦ CBC, INR, PTT, fibrinogen and D-dimer every 2 days. If there is evidence of DIC,
then testing should be more frequent and at least daily. A markedly elevated D-
dimer (>3-4 fold) is a poor prognostic marker
◦ If the INR, PTT and fibrinogen are normal on day 4, then only check coagulation
labs if there is a concern for clinical deterioration, bleeding or thrombosis
Proposed algorithm for VTE risk stratification
(Aryal et al., 2020)

Bleeding score and Well’s score
(Obi et al., 2020)

(Obi et al., 2020)
Diagnosing VTE
One recent study found a sensitivity of 85.0% and specificity of 88.5% for
diagnosing VTE in patients with D-dimer levels >1.5 mg/L, but the study was
based on a small sample size (Cui et al., 2020)
Doppler ultrasound compression at lower and upper extremities
Bedside echocardiography to assess for right ventricular strain associated
with PE may be difficult to obtain due to patient instability or the
requirement of prone positioning in patients with acute respiratory distress
syndrome (ARDS)
However, in the clinical context of unexplained sudden deterioration of
pulmonary status or acute lower extremity erythema or swelling, these
tests may be useful in aiding the clinical suspicion for VTE
Guidance Statement 1:
Diagnosis of VTE in hospitalized COVID-19 patients:
a. Practitioners should use standard-of-care objective testing (i.e., CTPA, V/Q scan, MRI
venography, Doppler ultrasonography) to diagnose VTE based on clinical index of suspicion.
A pragmatic approach (i.e., point-of-care bedside ultrasonography or echocardiography) can
also be combined with standard-of-care objective testing (50% of respondents).
b. Routine screening for VTE using bedside Doppler ultrasonography of the lower extremities
or based on elevated D-dimer levels is not recommended.
Spyropoulos, A.C., Levy, J.H., Ageno, W., Connors, J.M., Hunt, B.J., Iba, T., Levi, M., Samama, C.M., Thachil, J., Giannis, D., Douketis, J.D. and (2020), Scientific and Standardization Committee Communication: Clinical Guidance on the
Diagnosis, Prevention and Treatment of Venous Thromboembolism in Hospitalized Patients with COVID‐19. J Thromb Haemost. Accepted Author Manuscript. doi:10.1111/jth.14929
VTE prophylaxis in sick ICU Hospitalized COVID-19 patients:
a) Routine thromboprophylaxis with prophylactic-dose UFH or LMWH should be used after
careful assessment of bleed risk. Intermediate-dose LMWH (50% of respondents) can also be
considered in high risk patients. Patients with obesity as defined by actual body weight or BMI
should be considered for a 50% increase in the dose of thromboprophylaxis. Treatment-dose
heparin should not be considered for primary prevention until the results of randomized
controlled trials are available.
b) Multi-modal thromboprophylaxis with mechanical methods (i.e., intermittent pneumonic
compression devices) should be considered (60% of respondents)
ANTICOAGULANT STRATEGIES
(Obi et al., 2020)

Duration of VTE prophylaxis for hospitalized COVID-19
patients:
a) Either LMWH (30%) or a DOAC (i.e., rivaroxaban or betrixaban 30% of

respondents) can be used for extended-duration thromboprophylaxis.
b) Extended post-discharge thromboprophylaxis should be considered for all

hospitalized patients with COVID-19 that meet high VTE risk criteria. The
duration of post-discharge thromboprophylaxis can be approximately 14 days at
least (50% of respondents), and up to 30 days (20% of respondents).
VTE treatment in hospitalized COVID-19 patients:
a) Established guidelines should be used to treat patients with confirmed VTE, with advantages of LMWH
in the inpatient setting and DOACs in the post-hospital discharge setting. A change from treatment-dose
DOAC or VKA to in-hospital LMWH should be considered especially for patients in critical care settings or
with relevant concomitant medications, and dependent on renal function and platelet counts.
Anticoagulant regimens should not change based solely on D-dimer levels.
b) A change of anticoagulant regimen (i.e.,from prophylactic or intermediate-dose to treatment-dose

regimen) can be (50% of respondents) considered in patients without established VTE but deteriorating
pulmonary status or ARDS
c) The duration of treatment should be at least 3 months (50% of respondents)
SHOULD COVID-19 PATIENTS RECEIVE POST-
DISCHARGE THROMBOPROPHYLAXIS?
Patients hospitalized for acute medical illness are at increased risk for VTE for up to 90 days after discharge
This finding should apply to COVID-19 patients, though data on incidence are not yet available
It is reasonable to consider extended thromboprophylaxis after discharge using a regulatory-approved regimen
(e.g., betrixaban 160 mg on day 1, followed by 80 mg once daily for 35-42 days; or rivaroxaban 10 mg daily for
31-39 days)
Inclusion criteria for the trials studying these regimens included combinations of age, comorbidities such as
active cancer, and elevated D-dimer >2 times the upper normal limit
Any decision to use post-discharge thromboprophylaxis should consider the individual patient’s VTE risk
factors, including reduced mobility and bleeding risk as well as feasibility
Aspirin has been studied for VTE prophylaxis in low-risk patients after orthopedic surgery and could be
considered for COVID-19 VTE prophylaxis if criteria for post-discharge thromboprophylaxis are met
Patients should be educated on the signs and symptoms of VTE at hospital discharge
Kasus 1: Tn S, 54thn
MRS: 20 Mei 2020
Batuk kering sejak 3 hari, demam 3 hari SMRS, sempat 38,8C
Sesak napas disangkal, tapi mudah capek.
Nafsu makan turun. Anosmia (+)
Riwayat traveling disangkal. Tinggal di Jakarta Timur
RPD: DM sejak 3 tahun, tdk berobat. Tidak merokok
Pekerjaan: pedagang.
Hb SOBIRIN 2543296 pulang
20 Mei
13,6
22 Mei
13,4
25 Mei
AGD:
27 Mei
AGD:
28 Mei 29 Mei 2 Juni 4 Juni 9 Juni
Swab(-)
10 Juni 14 Juni
Swab(-)
hipoksemia alkalosis
Ht 39,6 39 Lekosit Leuko AGD:
pO2: 57 respiratori Swab(+) Swab(+) 14.600 8100 normal
Swab(+) SaO2: 89%
Leukosit 4.760 6.000
Swab(+)
Trombosit 145.000 155.000
NLR 4,7 NS-1: neg
Perburukan CXR
ALC 771 IgG/IgM + Sepsis Pneumonia RAJAL
Dengue: Ekskalasi AB : Meropenem+Levofloxacin
CRP 75 Pasang
neg/neg
NRM,
Onsite sejak awal SaO2 naik Perbaikan klinis+CXR
Demam→ D4 98-99%
PCT PCT: 0,25 PCT 46 PCT 6,5
PT 9,7 (10,3) 9,9 9,9
APTT 43,5 (34,8) 49,1 39,7 (34,8) 37,2 31,5
(34,8) (34,8)
Fib 360 478 385
(N:136-384) LMWH : 2 x 40 sc
D-dimer 380 1360 790 4090 1200 1160 3550 450
Troponin 3,2 12
SGOT/PT 31/24 HbA1c
11,2
Ur 34 Intensifikasi insulin : Rapid Acting dan Basal insulin
Cr 1,2 (eGFR 67)
Tn S, 54thn
Tgl 20 Mei 2020: Tgl 23 Mei 2020: Tgl 26 Mei 2020:

paru ground glass opacity kanan bawah GGO dikedua paru relatif bertambah Konsolidasi inhomogen lapangan bawah kedua paru dan GGO
Kesan: Pneumonia kanan Kesimpulan: dibanding ro sebelumnya, kedua paru bertambah
lesi dikedua lapang paru relatif bertambah Kesan: dibandingkan torak tgl 23-5-2020 perburukan
Tgl 3 Juni 2020: Tgl 9 Juni 2020:

GGO kanan sangat berkurang dibanding Ro lama tgl 26.5.2 GGO paru kanan berkurang.
020. Kesan: perbaikan Kesan ; Dibandingkan torak tgl 3-6-2020 perbaikan
TERAPI
➢Oseltamifir 2x75 mg
➢azitromisin 1x500mg
➢HCQ 2x200 mg
➢Vit C 2x400mg IV
➢Ranitidine 2x50 mg
➢Sucralfate 3x15 ml
➢Rapid Acting dan Basal insulin
Disclaimer: Enoxaparin is indicated for prophylactic treatment of DVT in patients who are bedridden due to an acute medical condition such as heart failure (NYHA class III or IV), acute respiratory failure, episode of acute
infection or acute rheumatic disorder associated with at least one other risk of VTE factor. Enoxaparin is not indicated specifically to treat Covid-19 patients. Registration condition differs internationally, therefore
Enoxaparin might have different indication approval outside Indonesia
Kasus 2: Tn D, 49thn
❑Masuk RS: 17 Juni 2020

❑Pasien rujukan dari RS luar sdh dirawat 4 hari, dengan keterangan sudah 2x swab SARSCoV2 hasil positif.
❑Demam sempat 390C, sakit kepala, Batuk kering, Napas tidak nyaman, nyeri dada(+) ditengah.sejak 9 hari
SMRS.
❑Mual, tidak ada nafsu makan.dan bab cair 3hari yg lalu.
❑Tinggal di Jakarta Pusat. Riwayat traveling disangkal.
❑RPD: DM disangkal. Merokok 1 bungkus/hari
❑Pekerjaan: karyawan swasta.
▪Pemeriksaan Fisik :
▪ Ku CM, tampak sesak, RR 32 x/m ,nadi 130 x/m.
▪ Jantung S1/S2 regular,gallop negative
▪ Paru vesikuler, ronkhi positif kedua lapangan paru .whesing negative.
▪ Abdomen lemas ,hepar dan lien tak teraba,BUS normal.
▪ Ekstremitas akral hangat, edema negative .
▪Masalah: Covid 19, gagal napas tipe 1→ syok→ARDS
▪ Pneumonia bilateral, sepsis
▪ Hiperkoagulasi. Resiko VTE
▪ Myocardial injury
▪ Terapi:
▪ Levofloxacin 1x750 mg IV, Meropenem 3x1 gram, cefotaxime 3x1 gram, vit C 2x400 mg, oseltamifir 2x75
mg, zink 1x20 mg, NAC 3x200 mg, dexamethasone 1x3 mg, heparinisasi 20.000 U/24 jam, clopidogrel
1x75mg, ramipril 1x1.25 mg, sucralfate 3x15 mg, ranitidine 2x50 mg IV, laxadine 1x15 mg, Lasix 1x1ampl.
Tn. D 17 Juni 18 Juni 19 Juni 20 Juni 21 Juni 22 Juni
Swab(+) Kultur
Hb 49thn 11,8 11,9 Swab(+)
Sputum:
10,8 12,1
Ht 33,5 34,7 Gram (-) 32,5 38,6
Leukosit 15.850 17.500 Ekskalasi AB: 21.210 19.330
Ekskalasi AB:
Trombosit 195.000 289.000 Meropoenem 224.000 Meropoenem 250.000
NLR 18,2 26,91 + 34,85 + 9,09
IgG Vasopressor
ALC 795,5 612,5 572,67 Vasopressor 1836,35
SARSCoV(+)
CRP 375,8 (N<5) 347 Syok Sepsis + multiorgan failure 79
PCT 0,26 35,4 0,1
PT 11,9 (10,3) 11,9 11,4 10,7 11,3 11,7
APTT 47,2 (34,8) 48,1 52,2 39,3 38,6 39,6
Fib 809 (N:136-384) 498,5 424,3
D-dimer 27.300 (N<500) 7770 13.140
Troponin 130 (N<26)
Unfractionated16,9
Heparin iv drip 14,7
SGOT/PT 53/54 118/105 26/52
Ur/Cr/eGFR 17/0,7/127 29/0,6/156
AGD: Hiposemia AGD: normal AGD: AGD perburukan
SaO2: 89-90% dg NRM Hiperkapnia hipoksemia MENINGGAL
Onsite sejak awal Intubasi → Ventilator
Demam→ D9
Tn. D, 49thn
Tgl 17 Juni 2020: Tgl 18 Juni 2020: Tgl 21 Juni 2020 (pkl 11):
Subpleural konsolidasi kanan kiri tengah bawah Dibanding radiografi sebelumnya tampak sedik Dibandingkan torak tgl 18-6-
Kesimpulan : Pneumonia bilateral typical covid it perbaikan infiltrat paru, dengan ETT dan CVC 2020 sedikit perbaikan
insitu.
Tgl 21 Juni 2020 (pkl 19):

Dibandingkan torak tgl 18-6-2020 sedikit perbaikan
SPEKTRUM KLINIS
Gangg organ lainnya dan perburukan penyakit penyerta

HIPERKOAGULASI
DAN
COVID 19
D BIMA PURWAAMIDJAJA SpAn KIC MKes
SMF ANESTESIOLOGI DAN REANIMASI – INTENSIVE CARE UNIT

RS KEPRESIDENAN RSPAD GATOT SOEBROTO JAKARTA
PENDAHULUAN
1. Pasien sakit kritis daya kompensasi terbatas →
sistem imunitas.
2. Syok : imbalance kebutuhan metabolism
dengan asupan / delivery – perfusi.
3. Syok → respon stress → SIRS → Syok
berbagai derajat.
4. Syok : 3 hal : kebocoran kapiler, vasodilatasi,
aktivasi koagulasi → lingkaran setan.
5. Pasien sakit kritis : FAST HUG in BED PLEASE
→ THROMBOPHROPYLACTIC PREVENTION
6. Syok lokal → sistemik / meluas.
… pendahuluan
STROKE → syok otak → SIRS →

Neurogenic Pulmonary Oedema → Syok
sistemik.
UAP / STEMI / NON STEMI → syok

jantung → Acute Decompensated Heart
Failure → Syok sistemik
EMBOLI PARU → Syok paru → Acute

Respiratory Distress Syndrome → Syok
sistemik
HYPERCOAGULATION SHOCK SYNDROME

… pendahuluan
COVID 19
1. SIRS STORM
2. SYOK PARU : SUMBER OKSIGEN
3. GANGGUAN PRIMER PARU → ARDS
4. SYOK SISTEMIK AKUT
POTENSI
HYPERCOAGULATION SHOCK SYNDROME
C E G A H !!
&
ATASI !!
KASUS 1
Wanita, 61th masuk ICU dari ruang rawat isolasi
dengan keluhan utama sesak nafas. CM, gelisah TD
174/114, HR 135x, RR 35-40 x/menit, SpO2 96%
(O2 NRM 10 lpm). Dilakukan intubasi dan sambung
ventilator : vc simv, vt 360, ps 10, peep 10, fio2 60%
→ didapati SpO2 + 97%.
Pasien dirawat sebelumnya dengan diagnosa PDP
Covid 19, Impending gagal nafas ARDS,
Hipertensi gr 2.
…….…… Kasus 1
Laboratorium (H-1) Tatalaksana (H-1) ruang rawat isolasi
AGD DL Inf: RL 20 ml /jm
pH 7.515 Hb 12.7 Injeksi :

Azitromisin 1x 500 mg (H7)
pCO2 37,2 Omeprazole 2x 40 mg
L 11.430
PO2 84,5 Cernevit 1x 1 amp
Tc 207.000
HCO3 30,3 PO :
Neut 91 PCT 3x 500 mg
BE 7,6
Isoprinosin 4x 3 tab
SO2 95,5 Limfo 7 Retaphyl SR 2x 1 tab
Flumicil 2 x 600 mg
PFR 140 NLR 13 Lycoxy 2x 1 tab
Bioprexum 0-0-10 mg
D-dimer 4700 Amlodipin 0-0-10 mg
MP 3x 62,5 mg (tapp off)
Concor 1 x 2.5 mg
HCT 1x 25 mg
…….…… Kasus 1
H-5 (ruang rawat isolasi)
• Sesak nafas, TD 157/93, HR 125x → ICU isolasi → Resp:
vc simv, vt 360, ps 10, peep 10, fio2 60, RR 20x Sao2 97.
AGD DL D-dimer Inf: RL 20 ml / jm

Inj:
pH 7.532 Hb 12,3 3420
• Meropenem (2) 3x1 g iv
pCO2 40 Ht 36 Ginjal • Mycamin (4) 2x50 mg iv
• Enoxaparin iv bolus ekstra
PO2 160,7 L 17.870 Ur 113
dilanjutkan (1) 2x0.6 cc sc
HCO3 33,8 Tc 248.000 0.78 • MP 3x31.25 mg iv
• furosemid 3x20 mg iv
BE 11 Neut 86 82,31 PO:
• NAC 3x600 mg
SO2 96.6 Limfo 7 • Zinc 1x40 mg
PFR 160
• CPG 1x75 mg
NLR 12
• Aspilet 1x80 mg
Disclaimer: Enoxaparin is indicated for prophylactic treatment of DVT in patients who are bedridden due to an acute medical condition such as heart failure (NYHA class III
or IV), acute respiratory failure, episode of acute infection or acute rheumatic disorder associated with at least one other risk of VTE factor. Enoxaparin is not indicated
…….…… Kasus 1
• Hari 5 paska intubasi : Pasien di Trakeostomi

TDP.
• Hari 6 mode VCSIMV, TV 400, ps 6 peep 5 RR
6/20x/men → SpO2 98%. →Mode PSV PS 6
PEEP 5 FiO2 40% → sungkup trakeostomi dan
speaking valve 15 l/men.
• Hari 10 di ICU isolasi : GCS E4 M6 V5, TD:
152/84 mmhg, HR: 90x/m, RR: 23x/mSaO2:
98% (speaking valve 5 L/M).
• Hari 14 → pindah perawatan biasa.
…….…… Kasus 1
D-dimer (Ny DR – PDP)

13/4/20 16/4/20 20/4/20
D-dimer 4700 3420 1540
5000
4700
4500
4000
3500 3420
3000
2500
2000
1500 1540
1000
500
0
13/4/2020 16/4/2020 20/4/2020
D-dimer
KASUS 2
Pria, 70th, dirawat 5 hari di ICU isolasi, perburukan
Airvo fio2 80% sao2 60% → dinaikkan fio2 100 ,
Sao2 80% → dilakukan intubasi.
CM, gelisah TD 120/65, HR 115 (NE 0.1 mcg/kg/m)
, RR 35-40 x/menit, SpO2 96% (O2 NRM 10 lpm).
Dilakukan intubasi dan sambung ventilator : On vent:
vc simv, vt 400, ps 10 peep 10 fio2 80 RR 15x
Pasien dirawat sebelumnya dengan diagnosa Covid
19, Syok septik, MDRO.
…….…… Kasus 2
Laboratorium (H-5) Tatalaksana H-5
AGD DL Inf: RL 40 ml/ jm
Hb 8.7 Norepinefrin ~ MAP, saat ini 0.1 mg/kg/m
pH 7.453
Injeksi :
pCO2 24.4 Ht 25
• Azitromicin 1x500 mg (H5)
Leuko 25480
PO2 181.3 • Omeprazole 1x40 mg
Tc 242.000 • Enoxaparin bolus iv 0,4 cc ekstra,
HCO3 17.2
berikutnya enoxaparin (1) 2x0.6cc sc
BE -5.3 N 92
• Neurobion 1x1
SO2 95.5 L 3 • Vit c 1x1 gr
NLR 30.6 PO :
PFR 181
• Isoprinosin 4x3 tab (H12)
Ginjal LFT D- Fibrin • Xeloxy 2x1 tab
Ur 36 SGOT 34 dimer ogen • Hydrocloroquin 2x200 mg (H9)
Cr 1.06 SGPT 20 3760 949 • Fluoxetine 0-0-1/2 (10mg/) malam
Alb 2.8 • Vit b6 2x1
70.75
• VIP albumin 3x1
…….…… Kasus 1

TDP.
• Hari 6 mode VCSIMV, TV 400, ps 6 peep 5 RR
6/20x/men → SpO2 98%. →Mode PSV PS 6
PEEP 5 FiO2 40% → sungkup trakeostomi dan
speaking valve 15 l/men.
• Hari 10 di ICU isolasi : GCS E4 M6 V5, TD:
152/84 mmhg, HR: 90x/m, RR: 23x/mSaO2:
98% (spvalve 15 L/M).
• Hari 12 → pindah perawatan biasa.
…….…… Kasus 2
D-DIMER (Tn N – COVID 19)
21/4/20 22/4/20 27/4/20 30/4/20 1/5/20
3760
D dimer 3480 2030 2220 1210
Fibrinogen 949
40
38
35 35
30
25
22
20 20
15
12
10
5
0
D-dimer
KASUS 3
Pria, 63th, masuk ICU isolasi, RR 40x/m MRM 15 l/m
SpO2 98% → dilakukan intubasi.
CM, gelisah TD 120/65, HR 115 (NE 0.1 mcg/kg/m)
, RR 35-40 x/menit, SpO2 96% (O2 NRM 10 lpm).
Dilakukan intubasi dan sambung ventilator : On vent:
vc simv, vt 400, ps 10 peep 10 fio2 80 RR 15x
Pasien dirawat sebelumnya dengan diagnosa Covid
19, Septik, AKI, malnutrisi sedang, Hipoalbumin,
Stress ulcer melena.
…….…… Kasus 3
Laboratorium H-1
AGD DL Ginjal LFT
(Awal
masuk icu) Hb 13.9 Ur 141 31
Pasien Cr 1.33 55
pH 7.108 dilakukan Ht 42
56.49 2.4
pCO intubasi
91 L 16.480
2
PO2 160.3 VC SIMV, Tc 268.000
D dimer
Vt 300
HCO PS 12 1250
29 Neut 92
3
PEEP14
BE -1.6 Fio2 80 Lim 1
Sao2 98
NLR 92
SO2 98.3
PFR 161.8
…….…… Kasus 3
Tatalaksana H-1 di ICU

Inf: RL 20 ml/ jm
Dipeptiven 2x100 ml
Inj :
• Meropenem (1) 3x2g iv
• Tygecycline (1) 1x100mg iv
• MP (1) 2x62.5 mg iv
• Enoxaparin 0,4 cc bolus iv ekstra, dimaintenance Enoxaparin (1)
2x0.6 c sc
• Vit C 1x3 g iv
PO:
• Cotrimoxazole 3x960mg (H5)
• Alluvia 2x2 tab (H5)
• Isoprinosin 4x4 tab (1)
…….…… Kasus 3
• Hari 9 pasien desaturasi berulang → susp emboli

paru → bolus ekstra enoxaparin 0,4 ml iv ulang,
ditambahkan aspilet 2x80 mg dan CPG 1x75 mg.
TDP. Mode VCSIMV, TV 400, ps 6 peep 5 RR
6/20x/men → SpO2 98%.
• Hari 16 →Mode PSV PS 6 PEEP 5 FiO2 40% →
sungkup trakeostomi dan speaking valve 15 l/men.
• Hari 18 di ICU isolasi : GCS E4 M6 V5, TD: 152/84
mmhg, HR: 90x/m, RR: 23x/mSaO2: 98% (sp
valve 10 L/M) → pindah perawatan biasa.
…….…… Kasus 3
Tatalaksana H-9
Inf : PO :
• RL 20 ml / jm • Aspilet 2x80 mg
• Fentanyl 12.5 mcg/jm • Aluvia 2x2 tab (sd 7 hr)
• Hidonac (12.5/100) 1x • CPG 1x75 mg
• Cotrimoxazol 3x960 mg (sd 14
Inj : hr)
• Tygacil loading 100 mg, lanjut
2x50 mg iv
• Cernevit 1x1 iv
• Nb5000 1x1 iv
• MP (9) 2x62.5 mg iv
• Enoxaparin (9) 2x0.6 cc sc (ekstra
bolus iv 0,4 cc)
…….…… Kasus 3
D-DIMER (Tn O – COVID 19)

3/4/20 6/4/20 9/4/20 12/4/20
D-dimer 1250 1160 4350 4210
500
450 435 421
400
350
300
250
200
150
125 116
100
50
0
4/3/2020 4/4/2020 4/5/2020 4/6/2020 4/7/2020 4/8/2020 4/9/2020 4/10/2020 4/11/2020 4/12/2020
D-dimer
KESIMPULAN
1. Keadaan hiperkoagulasi sebagai salah satu

dampak sekunder infeksi Covid 19 penting
dikelola dengan serius.
2. Kegawatan akibat keadaan hiperkoagulasi bisa
berulang dan diperlukan kombinasi terapi.
3. Perbaikan klinis pasien salah satunya ditandai
dengan trend penurunan nilai D-dimer.
Introduction
COVID19
why coagulation disorder ?
IKE SRI REDJEKI

PERDICI/PERDATIN
PATOFISIOLOGI COVID-19
Mekanisme Invasi pada Sel Inang
• COVID-19 :
• Virus corona β : RNA rantai tunggal
• Siklus hidup : berikatan dengan reseptor, penetrasi, biosintesis,
maturase dan melepaskan diri.
Respon Sistem Imun
CYTOKINES ↑
IL-1, IL-6, TNF∝, IL-8, GM-CSF, dll
VIRUS ENTRY & INNATE IMMUNE CELLULAR HUMORAL

REPLICATION SYSTEM : APC IMMUNITY IMMUNITY
Mekanisme Invasi pada Sel Inang
• Berikatan dengan Angiotensi Converting Enzym 2

Gangguan Hemostasis
Ang 1-7 ↓ Ang II ↑
ENDOTHELIOPATHY
HYPERCOAGULOPATHY
Patofisiologi terjadinya kebocoran
kapiler pada COVID 19
Endothelium COAGULATION
CASCADE
Extrinsic pathway
Tissue Factor Plasminogen
of coagulation
Factor VIIIa
activator inhibitor PAI-1
CD14 IL-6
Organisms
IL-1
TNF-
Monocyte
Virus Factor Va
Suppressed
fibrinolysis
lypopolysaccharide THROMBIN TAFI
Neutrophil
Fibrin
IL-6
Tissue Factor
Fibrin clot
Inflammatory Response Thrombotic Response Fibrinolytic Response

to Infection to Infection to Infection
7/6/2020
Gagal Napas

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CASE SHARING :

TREATING CV PATIENTS DURING

Diah Retno Widowati, MD, FIHA, FAsCC

• Severe acute respiratory syndrome coronavirus 2 (SARS-

• Patients with cardiovascular (CV) risk factors and

• Patients with cardiac injury in the context of COVID-19

Pic from: https://rebelem.com/covid-19-thrombosis-and-hemoglobin/, accessed on 5 May 2020

KU : Sakit Sedang : GCS E4V5M6

• Heart : CTR 65%

Complete Blood Count Blood Chemistry Blood Chemistry

• Acute Decompensated Heart Failure pada CHF fc IV ec

KU : Sakit berat : GCS 4

• Heart : CTR 55%

Complete Blood Count Blood Gas Analysis +

• Penurunan kesadaran ec Hipoglikemia pada DM tipe 2

• Acute STEMI inferior late onset • O2 3 lpm

(> 12 jam) • Asetosal 160 mg loading → 80 mg OD IO

• Sesak nafas dan nyeri ulu hati berkurang.

• A number of randomized controlled trials have been developed to

• Interim guidance on recognizing and managing coagulopathy in

J Thromb Haemost. 2020;18:1023–1026.

• Chronic Anticoagulant and Antiplatelet Therapy:

• Venous Thromboembolism Prophylaxis and Screening:

http://www.inaheart.org/guidelines, accessed on 14 April 2020

http://www.inaheart.org/guidelines, accessed on 14 April 2020

Degree of Anticoagulation HOW TO

Subherbal S et.al, Circ 2009; 119: 1873

• Recognition of symptoms, which may be challenging due to atypical

• The management of ACS in the Covid – 19 era requires specific

ww.thelancet.com/haematology Vol 7 June 2020

Patofis: Cytokine Strom

D-dimer & prolonged PT sebagai prediktor mortalitas

The signs and symptoms of a PE include:

Our findings reinforce the recommendation to strictly apply

• Klok FA, et al. Thrombosis Research 191 (2020) 145-7.

(Aryal et al., 2020)

(Obi et al., 2020)

(Obi et al., 2020)

a) Either LMWH (30%) or a DOAC (i.e., rivaroxaban or betrixaban 30% of

b) Extended post-discharge thromboprophylaxis should be considered for all

b) A change of anticoagulant regimen (i.e.,from prophylactic or intermediate-dose to treatment-dose

c) The duration of treatment should be at least 3 months (50% of respondents)

Tgl 20 Mei 2020: Tgl 23 Mei 2020: Tgl 26 Mei 2020:

Tgl 3 Juni 2020: Tgl 9 Juni 2020:

❑Masuk RS: 17 Juni 2020

Tgl 21 Juni 2020 (pkl 19):

Gangg organ lainnya dan perburukan penyakit penyerta

D BIMA PURWAAMIDJAJA SpAn KIC MKes

SMF ANESTESIOLOGI DAN REANIMASI – INTENSIVE CARE UNIT

STROKE → syok otak → SIRS →

UAP / STEMI / NON STEMI → syok

EMBOLI PARU → Syok paru → Acute

HYPERCOAGULATION SHOCK SYNDROME

Laboratorium (H-1) Tatalaksana (H-1) ruang rawat isolasi

AGD DL Inf: RL 20 ml /jm

pH 7.515 Hb 12.7 Injeksi :

AGD DL D-dimer Inf: RL 20 ml / jm

• Hari 5 paska intubasi : Pasien di Trakeostomi

D-dimer (Ny DR – PDP)

• Hari 5 paska intubasi : Pasien di Trakeostomi

D-DIMER (Tn N – COVID 19)

21/4/20 22/4/20 27/4/20 30/4/20 1/5/20

Tatalaksana H-1 di ICU

• Hari 9 pasien desaturasi berulang → susp emboli